Plenary, 20 Nov 2003

Meeting date: Thursday, November 20, 2003

Official Report 819KB pdf

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Dental Services

The next item of business is a statement by Tom McCabe on modernising dental services in Scotland. The minister will take questions at the end of his statement; therefore there should be no interventions.

The purpose of my statement today is to advise of the Executive's intention to undertake a consultation on the future arrangements for primary care dental services in Scotland. Consultation is required to deliver the undertaking in the Executive's white paper "Partnership for Care" that we would take forward, in discussions with the dental professions and the general public, proposals for changes to the system for rewarding primary care dentistry, in order to promote prevention, improve access to services, and improve recruitment and retention.

I recognise the growing concerns of patients, practitioners, national health service boards and MSPs about the current system. It is clear to me that we need to take a fundamental look at how dental services are provided in Scotland. The dental health of the people of Scotland is poor, and is strongly related to deprivation. In national surveys, a small minority of children—often the poorest—were found to experience the majority of dental decay. For example, in 5 year olds, 50 per cent of decayed surfaces were found in just 9 per cent of children. Currently, only 45 per cent of children have no experience of tooth decay on starting school at 5 years of age. Adult dental health also remains poor. Forty one per cent of dentate adults in Scotland reported having some dental pain in the previous 12 months.

Although the number of dentists has been increasing incrementally in Scotland, there is evidence that we have an inadequate supply for NHS services. Fifty-one per cent of adults and 35 per cent of children are not registered with a dentist, although some of those do still access NHS services on an occasional basis. NHS boards have reported that an increasing number of dentists are deregistering patients from continuing care and capitation arrangements and increasing their percentage of private work. The hospital dental service is under pressure, as it is picking up a number of patients on an emergency basis who were previously seen by general dental practitioners. The community dental service is facing increased pressures from reduced availability of NHS dentistry, either as a result of failure to recruit dentists to a particular area or the reducing commitment to the NHS of existing practitioners. Problems of access to NHS dentistry in certain areas have been the subject of legitimate public and media interest, and I have received representations on the subject from many MSPs.

The remuneration system for dentists and the consequent charging system, which patients find opaque, have remained largely unchanged since the establishment of the NHS. In conjunction with the dental professions, we have already introduced a number of measures in Scotland in the past two to three years, aimed at addressing access and recruitment issues. While those measures have had some effect, I have concluded that the present delivery system is unlikely to be sustainable in the longer term and that a different form or forms of provision will be necessary to sustain an acceptable level of service and secure the improvements in oral health that we so badly need.

In the partnership agreement, we have undertaken systematically to introduce free dental checks for all by 2007. We also recognise the need to increase the number of dentists and dental graduates in Scotland and we will expand the capacity of dental training facilities in Scotland by establishing an outreach training centre in Aberdeen.

Notwithstanding those commitments, I consider that it would be appropriate to consult interested parties on the future form of primary care dental services in Scotland. To take forward the process, the Executive is today launching a consultation on possible options for the future. The consultation document, "Modernising NHS Dental Services in Scotland", sets out the background to oral health and dental services in Scotland, provides a summary of what has already been put in place to support NHS dental services, describes the pressures and the need for further change, and puts forward options for changing the current system, including patient charges. The consultation process will include discussions with interested parties, including representatives of the NHS, the professions and the public. We will undertake in the new year a number of consultation meetings around Scotland. It is recognised that any substantial change to the current system will require legislative change. Following consultation, we will consider bringing forward legislation at a suitable opportunity.

Substantial changes may take some time to implement and it is important that we continue to develop short-term measures to address the current problems. In that regard I am pleased to announce some changes to existing Scottish initiatives and the introduction of several new measures. Some of those measures will contribute to the recruitment of dentists from the European Union. With regard to existing initiatives, we will double the remote area allowance from £3,000 to £6,000, we will double the allowance for vocational trainees in designated areas to £6,000, and we will double the allowance to recent graduates entering general dental services to £10,000, and double it again to £20,000 for designated areas. We will double the access grant for new NHS practices to £100,000 and double the grant for extending existing practices to £50,000.

In addition I am happy to announce a new range of Scottish initiatives: a new allowance for vocational trainees in non-designated areas of £3,000; a new allowance of £5,000 for joining a dental list for the first time or for re-entry after a five-year break—that allowance will double to £10,000 for designated areas; a new allowance of £10,000 for salaried dentists employed within three months of completion of training—that allowance will double to £20,000 for designated areas; and a new allowance of £5,000 for dentists who join the salaried dental service for the first time—that allowance doubles to £10,000 for designated areas. The increases to existing allowances and the introduction of new allowances will take effect from 1 April 2004.

So far I have announced our plans for the medium term, via the consultation process; and for the short term, via the new and enhanced initiatives. However, I recognise the urgency required in some areas. Consequently, I am pleased to announce, with immediate effect, £1.5 million to establish new emergency dental services provided by NHS boards and to support existing ones. That emergency capacity will minimise the risk that anyone will experience pain for an unacceptable time. That new money is in addition to the funding for such services that is available under the general dental services budget.

Substantial change will not happen overnight and it will be a challenge—because of the complexity of the issues and the importance of making dental service delivery more effective. I hope that we will be able to work together to achieve what I have set out and that, in doing so, we will produce a high-quality NHS dental service that delivers on the needs of patients and the aspirations of the dental professions and which makes a substantial impact by improving the health of the people of Scotland.

The minister will take questions on his statement. I will allow until 1 o'clock for questions.

I thank the minister for an advance copy of his statement.

I welcome much of his statement, but I will ask about the short-term measures that have been announced, many of which depend on an increase in the supply of dentists. Where will the dentists to meet those short-term objectives come from? As the situation is urgent, what is the time scale for making proposals after the consultation period is complete? On the important matter of patient charges, will the minister say what proportion of dental costs the Executive thinks it reasonable for patients to pay and how the Executive will ensure that that is fair and equitable?

We have made it clear that the supply of dentists is important. Of course, there are about 120 dental graduates each year in Scotland. We are committed to increasing that number. That is why the partnership agreement contains a commitment to establish an outreach centre in Aberdeen. We are committed to examining the possibility of upgrading that to a full training centre if that is required.

As for time scales, we await a legislative opportunity. I have acknowledged in the statement and in previous answers to questions in Parliament that the situation is urgent. We recognise the importance of dental health, so I do not expect the Executive to want any undue delay in improving the delivery of dental services.

Patient charges are an issue that the consultation is designed to cover. As I said, we will discuss that not only with the dental professions, but with the public. We will take on board the views that we hear.

I, too, thank the minister for advance copies of the consultation document and his statement.

I welcome many parts of his statement—particularly the consultation of patients and progress on the outreach facility in Aberdeen, which is welcomed in the north-east. I also welcome the comments in the consultation document on considering insurance-based dental plans, because of the huge funding implication, at which Shona Robison hinted. However, I hope that the proposed allowances are not only for relocation to new areas, unless they are intended to meet disabled access needs. I regret that the minister did not comment on upgrading the old-fashioned list of materials that are available for NHS treatment.

Why should free check-ups be given to those who are well able to afford them? I echo Shona Robison's question about where the Executive will find the bodies for the short-term measures. Extra people are required, not only to be salaried dentists, but to be hospital specialists. The minister commented little on that.

Why will the minister not implement support packages, such as interest-free loans, for European Community dentists while they complete their short pre-registration training? That would be one of the easiest ways to meet some of the short-term difficulties.

I have said many times, and our partnership agreement contains a firm commitment on the fact, that we recognise that dental health in Scotland is poor. We are determined to make a substantial difference to that. People in Scotland have warmly received our proposal to make available free dental check-ups to all in Scotland by 2007, which will be part of the process of substantially improving dental health.

The consultation should also be part of that. I have acknowledged explicitly that delivery methods in the dental health service in Scotland are no longer appropriate and need to be modernised. I am confident that, in modernising those delivery mechanisms, we will make substantial progress on dental health in Scotland.

We have announced today a range of measures, both to upgrade existing provision and to support new initiatives. We are confident that those measures will make a difference to the supply of services and to the thinking of some of the dentists who have deregistered patients, allowing them time to consider, both in the context of the initiatives and in the context of the consultation that the Executive is now launching, whether it is still appropriate for them to spend so much time in private practice or whether they want to turn their attention once again to the national health service.

Introducing further financial incentives to recruit new dentists is really good news. The Liberal Democrats are pleased that the Executive has accepted that we need to train more dentists in Scotland, which is excellent. I have a specific question on the commitment in the partnership agreement for the outreach centre in Aberdeen. The minister previously announced that £100,000 would go towards funding the research work that is needed for that. Can he give us some idea of the time scale in which those plans will be complete and ready to take forward to the next stage?

Mr Rumbles has quite rightly identified the fact that we previously announced that £100,000 had been made available to establish the planning process that is necessary for that outreach centre. As I said at the time, we expect a conclusion to be reached within six months and we hope that, thereafter, the process will move ahead without any undue delay.

I whole-heartedly welcome the quick response to representations that have been made to the minister on this important subject. He is aware that NHS dental services have, in effect, been withdrawn from large numbers of communities around Scotland—most recently from Longniddry and Haddington in my constituency. I also had a letter from my own dentist in the Borders last month giving notice of imminent withdrawal of NHS services. Is it the Executive's intention that NHS dental services should be restored in areas where they have been lost, so that every citizen of Scotland will again have local access to dental treatment under the NHS?

That is exactly what our intention is. We recognise that the dental service clearly needs to be modernised. We are in the process of modernising a whole range of areas within the national health service, including junior doctors and consultants—the list goes on and on. Dentistry needs the same attention, as it plays such an important role in Scotland. It is very important for the general public in Scotland to know that when they need access to NHS dentistry, it is there for them, when and where they want it.

As from now, I expect shorter questions and answers. I call Eleanor Scott.

I welcome the consultation document, because dental health has been a big issue up in the Highlands, where I come from. I seek an assurance that the consultation meetings referred to will take place in the most rural areas, so that people there who are really suffering from a lack of dental services will be able to make their views known. I hope that the absence of the F-word—fluoride—from the document means that the Executive is now abandoning the idea that that would solve our dental health problems. There is no substitute for dental services.

I can give an absolute assurance that the consultation meetings will take place in every part of Scotland. Given the problems that have been experienced in rural areas in the recent past, there will undoubtedly be a series of meetings in the Highlands of Scotland.

The Executive expects to respond to the children's oral health consultation in the near future, and perhaps Eleanor Scott will get the response that she is looking for at that time, or perhaps she will not.

I also welcome the minister's statement and thank him for responding to views expressed by MSPs from around the country. How many dentists will have to be recruited nationally before the minister can achieve his objectives? What discussions has he had with the Minister for Health and Community Care, Malcolm Chisholm, with regard to the shortage of specialist consultants and theatre staff, whose work is also related to this important topic?

With regard to the number of dentists, our work force planning arrangements continue to keep such matters under review. That is why we are considering an outreach centre in Aberdeen and are prepared to consider the possibility of upgrading it if necessary. That is why we are consulting members of the dental professions: to hear their views on exactly what needs to happen. The thread that runs through the entire document is that nothing is ruled out.

I speak regularly to Mr Chisholm about a range of matters concerning dentistry and specialisms. We are both aware that the problems of dentistry require a wide range of solutions, and we are both continually working to deliver those solutions.

I acknowledge the excellent work that Paul Martin and the dental think-tank are doing in the Highlands and I hope that the minister will work with them, as many MSPs have done.

Will the minister include in the consultation the issue of free dental care for the elderly and for people who are on benefits who currently have to pay the full fees for dental treatment? If those people need their dentist to issue a prescription, they have to pay a fee to an NHS dentist and the full cost of the prescription to a private dentist. That leads to serious financial hardship.

A moment ago, I said that the fact that nothing will be ruled out will be the thread that runs through the consultation. Clearly, we will listen to whatever representations are made during the consultation and take on board as many of those as we can. As with any consultation, we will be able to accept some arguments and not others, but where we cannot respond to demands, we will be obliged to explain why we do not think it appropriate to do so at that time.

I have mentioned the commitment in the partnership agreement to the introduction of free dental checks for all by 2007. The Executive is examining how best to implement that commitment.

Like the other members who have spoken, I welcome the minister's announcement of a substantial package of remote allowances and other incentives to encourage more people to go into dentistry. Of course, there will be a delay in the implementation of the whole package. That must be addressed.

Does the minister think that, as we encourage more students to go into dentistry, we should consider offering some sort of incentive to students, to ensure that after they qualify they are retained within the NHS? As the minister knows, people who qualify as dentists do not always lend their services to the NHS.

Both the new and the existing initiatives that I have spoken about today encompass a realisation that when allowances are paid, some degree of commitment is expected from new graduates within the NHS, so there is a degree of tie-in in that regard.

I note from the minister's statement that the most significant problems arise in areas of deprivation. How will the measures that he has announced ensure that we address that specific issue?

To reply in general terms, the modernisation of the dental service and the fact that we will allow the service to concentrate on specific issues—as it has been asking to do for a considerable time—will address that matter. It would be desirable for the service to concentrate on young people, to try to stop the rot—if members will pardon the pun—as early as possible. In areas of deprivation, a modernised dental service that offers more flexibility and frees dentists from the bureaucracy that has tied them down for far too long will provide opportunities to target specific groups in the community to improve people's dental health.

I refer the minister to the statement that he issued—rather than the one that he delivered—in which he names the designated areas, one of which is the Scottish Borders. Given that my constituents, from Hawick to Peebles, have like many other people been turned away from NHS dentists, and given that the allowances will not, as I understand it, come into effect until 1 April, can the minister give a time scale for when my constituents will again be able to access NHS dental services?

On a point of order, Presiding Officer. I might be mistaken, but did Christine Grahame refer to a copy of the minister's statement? I would like to make the point that copies were not made available to other back benchers.

I seek your guidance, Presiding Officer. I was simply seeking to assist the minister, who referred to designated areas but did not define them, as he did in his statement as issued.

There is a point here. I will consult the clerks and I suggest that we continue with questions in the meantime.

There is a complete list of designated areas and, as Christine Grahame will know, it includes mainly rural areas, where access problems have been most severe. I understand her point; the new allowances and initiatives do not come in until 1 April next year. However, a range of initiatives are in place and have made a contribution. As I said earlier, the signal that we send today to the dental professions will give food for thought to dentists about the Executive's intentions and about what the future holds for them. I am confident that they will reconsider many of the decisions that they have taken.

Is the minister aware that no NHS or private dentists in my constituency have open lists? Will he assure us that the welcome measures will be monitored closely and regularly to ensure that they work in areas such as mine? Will the Executive consider making it possible for NHS boards to give people who are on low incomes financial assistance to enable them to travel to other NHS board areas to access dental health treatment?

NHS boards can contact the Executive and request our thoughts on a range of issues, one of which is travelling expenses. If a case is made for the provision of such expenses, we would, of course, consider it. I recognise the severe problems in the member's area. I recount again that, in my statement, I announced £1.5 million for enhanced emergency dental services, which, I hope, will reduce an awful lot of the pressure in the worst-affected areas. That £1.5 million is in addition to the money that is already available to NHS boards for the provision of emergency dental services.

Does the minister anticipate that dental services might increasingly be provided alongside primary medical services—in community hospitals, for example—to increase access to primary dental services for people of all ages in remote and rural Scotland?

I hope that that is the case and that that will be possible. As we modernise primary care services and consider how we can bring together a range of allied health professionals to deliver a more comprehensive local service, where the opportunity exists to do what Nanette Milne suggests, I hope that it will be taken up. I hope that our opening up of the question of modernising the dental health service will allow far more discussion between GPs, dentists and a range of other allied health professionals. That will allow them, on their own and in conjunction with health boards, to consider how best to arrange services to serve patients' needs better.

I welcome the minister's statement. Will he confirm that, in proceeding with the package of work, he will seek radically to reduce the bureaucracy and complexity of the existing fees and charges system? Will he seek to establish a fairer and more transparent system that is significantly more comprehensible to dentists and patients than the current one is? Does the minister agree that dentists would say that we must address both prevention and cure? Will he confirm that the dental professions are overwhelmingly of the view that fluoridation is the biggest single measure that could be taken to improve dental health in Scotland?

To address the final point first, we will respond to the consultation on children's oral health in the near future. I know that I risk giving a less than complete answer to Susan Deacon, but I do not want to pre-empt that announcement.

Susan Deacon has gone to the heart of the problems of dentistry in Scotland by mentioning bureaucracy and the charging system. Dentists are weighed down. I took the time to speak to a number of dentists throughout Scotland in the summer, who told me that the way in which they are monitored and the bureaucracy that affects their practices discourages them and encourages them to leave the NHS and consider private practice. As I said in my statement, the general public do not understand the charging system and it is time for a great deal of simplification. If nothing else comes about as a result of the consultation, I hope that we will make radical changes to bureaucracy and the charging system.

I welcome the minister's statement. He talked about the partnership agreement delivering free dental check-ups, but also about the difficulty of telling members when any changes will come about following the consultation period. Will he at least give members the assurance that changes to the provision of services will come about first, before the introduction of free dental checks? Surely it would be absurd to give something free that is not provided at all.

I do not think that there would be anything absurd about the provision of free dental checks to people throughout Scotland. The reaction, so far, to that commitment in the partnership agreement has been a wide and warm welcome throughout Scotland. Perhaps Mr Monteith's question reflects the jealousy of the Tory party because it did not come up with such a proposal.

We are going to talk to the dental professions and take their advice about how we can best honour the commitments that we have made. We want to stick to our commitments and will speak to the professionals about not only how we can implement those commitments, but how we can augment them, taking on board their experience and the political commitment that exists in the partnership so that we can make substantial improvements to the dental health of people in Scotland.

In view of the widespread dental ill health that exists in Scotland, which the minister has acknowledged, will he consider changing the rules so that, as happens with general medical services, health boards are required to find an NHS dentist when a patient cannot?

A series of changes are going on relative to the responsibilities that health boards have. In some of the forthcoming legislation, we will establish community health partnerships and, through those, a substantial range of alterations to the way in which things are done may take place.

I am not going to say that I can instruct health boards to wave a magic wand and produce people who do not exist in an area. What we can do, following the announcements that have been made today, is supplement what is available to NHS boards through the provision of emergency dental health services. We have allocated a substantial amount of money today, and that will make a contribution.

I apologise to the seven or eight members who have not been called to speak.

In regard to the point of order that was raised by Mr McNeil, I still need some further information. However, I judge it to be fair for Christine Grahame to have referred to an advance copy of the statement if it was issued by the minister, whether or not he included it in his speech.

Presiding Officer, I seek your guidance on a matter concerning constituency members. Is it in order for regional members to use such a statement—which has been offered to the front-bench spokesmen of Opposition parties—to raise constituency cases when that is an opportunity that back-bench constituency members such as I do not have? Can you offer guidance as to how such statements are given out? If they are given to front-bench spokespeople, what are the rules regarding that?

I can hardly be expected to give guidance immediately, Mr Purvis. However, I will reflect on the matter and will come back to you personally, or perhaps to the chamber.

It might be helpful if you were aware, Presiding Officer, that I was asked by my colleague about the list of designated areas, which is unchanged. I noticed that it was on the document that was in front of my front-bench colleague, which I passed back to provide the information. It is therefore down to me, Presiding Officer.

I take that as confirmation that the minister did not give the statement to Christine Grahame. I do not have any great objection to the statement's going to Christine Grahame, as she is the convener of the Health Committee; however, it may be that every member should have been given a copy. We certainly were not.

Presiding Officer, can you confirm that, as soon as a minister sits down, the statement is available to all members anyway at the back of the chamber, as previously agreed, and that every member had access to that statement as soon as the minister sat down?

The point is that Christine Grahame did not get it after the minister sat down. She had it and had been given privileged information. That needs to be looked into.

For clarification, I did not have the statement in advance. Statements are available to all members. The rule is that, once the statement has been given by the minister, written copies are available. As has been stated, I was clarifying the position with regard to designated areas. I glanced at the statement, after the minister had sat down, to clarify the position with regard to the Borders. I did not have the statement in my position as the convener of the Health Committee.

On a point of order, Presiding Officer.

Do you really want to pursue this, Mr Scott?

I understand from my colleague David Davidson that copies of the statement were available from the Scottish Parliament information centre as soon as the minister had made the statement.

Thank you. I really do not want to pursue the matter now. We are in a situation of he said, she said. I cannot possibly make a judgment off the top of my head. I will reflect on the matter and come back to it when we return this afternoon.

Meeting suspended.

On resuming—